Asleep at the Table
If your taxi driver had been awake for the guts of 57 hours, would you be happy to let him drive you home? No?
What about if your doctor had been awake for 57 hours - would you let them take out your appendix?
Didn't think so.
Sunday Business Post, August 07, 2005
Working around the clock, grabbing a snooze when there's a lull in the action, going without meals and pepping themselves up with caffeine – how long can Ireland's over-worked junior doctors keep going under these conditions?
‘You wouldn't want your mother or father on that operating table,” says the junior doctor, yawning down the phone.
When pressed for detail, there's a long pause before she can recall her weekend with any clarity. She is shattered. For 57 hours, or almost two-and-a-half days, she and her team worked without once leaving the hospital. In scattered catnaps, she snatched three hours of sleep here, one or two more there. She got a total of eight hours sleep over nearly three working days.
Somewhere around hour 53, she was called to an emergency appendectomy with another surgeon on her team, their third of the weekend.
Exhausted, she left hospital for home at 6pm on Monday, having arrived for work at 8am the previous Saturday.
In Ireland, junior doctors work an average of 75 hours a week. A significant proportion of them work much longer hours. Many hospitals rely on junior doctors for on-site medical cover at night and at weekends. There are about 4,000 junior doctors in Ireland delivering frontline services in more than 40 public acute hospitals and in numerous other health agencies.
The reality is they work around the clock, grabbing a snooze when there's a lull in the action, going without meals and pepping themselves up with caffeine.
“Come Monday morning I didn't get a chance to go back to bed,” says the junior doctor. “I had three cups of coffee in a row before ward rounds, so was really buzzing until noon. After 12 it hit me like jet lag, my legs felt heavy.
“The day after any call [an on-call shift] is bad. It feels like you've run a marathon, you're on your feet all day, you get calluses and blisters from walking around so much.”
Not only is such a punishing work schedule dangerous for doctor and patient, it's also illegal. This month marks one year since the European Working Time Directive came into effect for junior doctors in Ireland. Non-consultant hospital doctors (NCHDs) work an average of 75 hours a week. But as of August 1, 2004, it was not legally permissible to require them to work more than 58 hours in a week.
The Working Time Directive came into being to prevent people from working to a level that impacts their health and wellbeing. In Ireland, it took the form of the Organisation of Working Time Act, under which employers must restrict their employees' working hours to stipulated levels.
This will taper down gradually to a maximum 48-hour working week in 2009. In addition, the directive stated that a worker must be allowed at least 11 consecutive hours rest in any 24-hour period.
However, failure to comply with the act will not land the employer with a fine or indeed any sort of charge. In fact, nothing at all will happen until an overworked employee demands the protection of the directive fromtheir employer. If the hours worked continue to exceed those stipulated in the directive, the employee must make a claim against their employer and follow that claim through, which is a difficult thing to do if you're a doctor working a 75-hour week, with the odd 57-hour weekend thrown in.
The directive was meant to address the much-vaunted concept of work-life balance, but for hospital workers it should have positive impacts for safety, too. Because by consistently going without sleep and missing meals, hospital doctors are building up what specialists term “sleep debt'‘.
A report by Stanford University fatigue specialist Dr Stephen Howard examines the long history of linkages between tiredness and industrial accidents. According to the report, the risk of an accident “increases exponentially with each hour of work'‘. After 24 hours of constantly being awake, the effects of tiredness on motor skills are equivalent to having a 0.1 per cent blood alcohol level, which is above the legal limit for driving a car. For hospital doctors, the buzz of the emergency is often what gets themthrough their shift. Having been on the job since 8am on Saturday, our junior doctor finally gets to bed at 3am on Sunday morning. She doesn't remember if she had dinner or not. Four hours later, she is called back to the ward to deal with a patient.
From the ward it's straight to the A&E to deal with a head injury. There's no time for breakfast, either, because her team has morning ward rounds to cover and by midday it's time for appendix removal number two. The surgeon she's assisting didn't have the luxury of four hours sleep. A road traffic accident kept him in the operating theatre all night.
“Four hours sleep, that's pretty good going,” the junior doctor says. “I've had calls where you only get two. I didn't get time for lunch on Sunday and kept going until about 11.30 that night'‘.
That's 19 hours work on Saturday, followed on Sunday by over 16 hours work without a break or a meal. She had four hours sleep in between, but has had to deal with a full patient workload all day Sunday on an empty stomach. Her responsibilities don't stop with the patients either. Despite being a junior doctor, her official title is Senior House Officer, which means she's also teaching, and responsible for her students' mistakes.
“We're supposed to help the interns,” she says. “We're teaching on the job, while being on call. I'm obliged to come to the ward if the intern has any difficulties.” The doctor has an assistant surgical role; however, sleepy mistakes could be just as critical in other areas of her work. “I don't have that much responsibility in theatre,” she says, “but I do have responsibility when admitting patients in casualty. You can't miss anything when admitting and ordering medication, but it's so easy to make mistakes when you're tired.”
Jo Harkness,policy officer of the International Association of Patient Organisations, says shorter working hours are in the best interest of patients as well as doctors.
“For patients to trust their health professional requires a level of understanding and communication,” says Harkness. “It's not just about time; it's also about the frame of mind that the doctor is in. If they're tired, it may be harder to communicate and listen and exchange information in an effective way with the patient.” According to Dr Howard, “error rates in the sleep lab go up significantly after 17 hours of continuous wakefulness. Error rates go up in clinical areas as well.”
He suggests that, while doctors may realise they are tired, their tiredness also negates their capacity to make decisions on their capability to perform. “This is about physiology and our attempts to ‘overcome' it,” he says. “The longer you push your physiological capability, the greater the likelihood that you will make an error or have an accident. In that situation we have no good way of telling how alert or sleepy we are, so we should be the last to judge.”
Without the implementation of the working time directive, decisions about long working hours remain in the doctors' hands. Under the legislation, individual doctors must ask their employer to bring their working hours in line with the provisions of the directive, ensuring they work no more than 58 hours per week. If the employer refuses, the doctor can take their claim to a rights commissioner and on to the Labour Court and the European Court of Justice. With many hospital doctors continuing to work well above the 58-hour limit, how many of them have actually asserted this right?
According to the presidentof the Irish Medical Organisation (IMO), Dr Asam Ishtiaq, none of the union's members has looked for its help on the issue. “There has not been an avalanche of people coming in saying ‘I want to be protected', because at the end of the day, what is the aim of a doctor in the Irish health service?” he asks. “We are professionals. Our aim is not to create trouble, we are trying to finish our training, continue the quality of training and be of service to the patients and the system.”
Reducing the working week of hospital doctors to 58 hours represents a loss of 22 per cent on current capacity, something that the health system as it stands could not support. “We either have to find a new way to conduct business and how to do things, or we have to employ a large number of doctors,” says Ishtiaq. “But option two does not exist.”
The Hanly Report on medical staffing, published in 2003, laid out a blueprint for such a transition. The implementation of its findings, while essential for achieving crucial improvements in the healthcare service, met with widespread opposition. The political will to invest in the major changes evaporated and working hours subsequently were not reduced. When the Working Time Directive was first negotiated, the governments of Britain and Ireland successfully sought to have doctors-in-training excluded from its scope. That exclusion was revoked by further legislation passed in 2000, which brought junior doctors under its full protection in autumn last year.
Despite that, Ireland has yet to fulfil its obligations and remains in breach of the legislation. However, the medical unions must shoulder some degree of responsibility for the lackof progress. Entwined within the complex negotiation process on working hours is a consultants' dispute involving the renegotiation of their common contract and medical indemnity insurance.
The consultants' union, the IHCA, has refused to enter negotiations on a new contract for the past two years. No new contract means no new consultants. And no new consultants means longer working hours for junior doctors.
“It certainly is a mess at the moment, and it's costing an enormous amount in overtime,” says Liz McManus, health spokesperson and deputy leader of the Labour Party. McManus's husband is a doctor and two of her children work as junior doctors. “Hanly is very long-term in perspective. The government certainly hasn't pursued it in any way that is perceptible, there's a lethargy at departmental level. “And even if they do say they are moving towards compliance, they are not addressing the concentration of [working] time.”
McManus points out that “there are countries in Europe that have been in compliance since before it [the act] even came into being. Here, we don't have enough consultants; we're far too reliant on junior hospital doctors. They're doing a lot more work than in other countries and it's not good for training.”
Her comments are borne out by a comparative study with Finland which found that, with a lower annual healthcare spend than Ireland in relative terms, doctors in the Finnish system work an enviable 43 hours per week. Finland's specialist-to-trainee ratio is five times that of Ireland. In order to phase in the requirements of the working time directive, the IMO has begun pilot studies of alternative work practices.
“Meanwhile, the patient and the junior doctors are in a bind,” says McManus. For the present, the unwritten rule, it seems, is that doctors must continue to work quietly under these conditions until a deal is sorted out that is beneficial to understaffed hospitals and doctors alike.
“There is sort of a ‘peace clause',” says Ishtiaq. “It's an agreement that all our members are aware that active representations are being made at the Labour Relations Commission to find a solution [to long working hours].” With low basic wage levels, many doctors accept the overtime hours because a working weekend effectively adds a week's pay to a wage packet.
“My hourly base pay is the same as a McDonald's manager,” says one junior doctor. “So if we do a 58-hour week we lose all our on-call hours, and don't make as much money. But what about patient care?”
The IMO is pushing for a basic rate of pay that allows doctors to earn a “living commensurate to their qualifications and the type of work they do'‘. Until that is provided, it says it is unreasonable to demand that they give up their overtime hours.
“The argument always given to us was that, since the opportunity to earn overtime is so high, the basic rates of pay always remained comparatively low.
“When the NCHDs no longer have the opportunity to earn enormous overtime hours - which are not of our choosing - there has to be a reciprocal increase in the basic pay,” says Ishtiaq.
Shift work is one way to go, he says. However, according to aRoyal College of Physicians survey published this year, 84 per cent of registrars felt that shift work reduced the continuity of patient care, 81 per cent reported excessive fatigue at work and 74 per cent admitted to having fallen asleep at work.
With a continuing stalemate between the medical unions and the government, junior doctors will continue to catnap their way through arduous shifts and rely on the buzz of the job to get them through.
“The thing is,when you get a call from casualty, there's this massive adrenaline rush, it's not like waking up with your alarm clock,” says one hospital doctor.
“You wake up and if it's something serious then your mind just suddenly switches on.”
Howard says that, while the likelihood of a major mistake occurring during such long shifts remains small, such suboptimal situations will continue to occur. “But has safety been impacted? Yes. Do you want this person performing your operation? No.”
He compares practising medicine while sleepy to driving a car.
“Driving while sleepy - close your eyes for five seconds going at 50mph and the possibility of a crash is very high. Practising medicine while sleepy, if you close your eyes for five seconds, nobody will notice.
“But safety has been impacted, it's just that we don't travel 50 miles per hour in healthcare.”
